Disturbed sleep pattern r/t inadequate
stimulation, poor sleep hygiene, and substance use as evidenced by client verbalizations
of “I sleep during the day because I have nothing to do,” reported use of a 3 servings
of alcohol daily, reported use of a pack of cigarettes daily and verbalization of
“I like to sit here and watch TV” while describing
her bedroom activities.

Short term goals:

1.Client
will identify personal habits that disrupt sleep pattern and strategies to improve
quality of sleep as measured by verbalization of at least two contributing factors
and strategies by 15:00 on [Month] 14, [Year].

2.Client
will express commitment to avoid daytime napping as a method of alleviating boredom
for one week as measured by a verbalization of agreement by 15:00 on [Month] 14, [Year].

3.Client
will describe alternate activities to avoid daytime nappingas a result of boredom measured by verbalization of at least three alternate
activities by 15:00 on [Month] 14, [Year].

Long term goals:

1.Client
will engage in daily activities that she finds interesting and feasible in lieu
of daytime napping as measured by observation and self report of daily participation
by 15:00, August 1, [Year].

2.Client
will regularly fall asleep without difficulty as measured by client verbalization
of ease of falling asleep consistently by 15:00, August 1, [Year].

3.Client
will wake less frequently throughout the night as measured by verbalization of less
frequent awakening compared to baseline by15:00, August 1, [Year].

4.Client
will verbalize the effects of alcohol and nicotine on sleep as measured by client
statements reflecting understanding by15:00, [Month] 21, [Year].

Obtain a sleep-wake history including history
of sleep problems, changes in sleep patterns, and use of medications and stimulants.
Assessment of sleep behavior and patterns are an important part of any health status
examination (Hilliker, [Year]).

Assess for use of alcohol or cigarettes
prior to use of sleep medication or retiring for the evening.Alcohol and nicotine should be avoided for several hours prior to sleep (Hilliker, [Year]).

Assess for underlying physiological illnesses
as a potential cause for nighttime sleep loss and daytime sleepiness (including,
but not limited to pulmonary, cardiovascular and gastrointestinal conditions).Symptomatology of disease states can
cause insomnia (Sateia, Doghramji, Hauri, & Morin,
2000).

Nonpharmacologic interventions have been
found to improve sleep efficiency and
increase satisfaction with sleep pattern while decreasing use of hypnotics (Morin, Mimeault, & Gagne, 1999).

Evaluate learning outcomes using patient
verbalizations of following the treatment recommendations and experiencing enhanced
sleep.Evaluation serves as an assessment
of the effectiveness of care and allows opportunity for adjustments to the plan
of care (Ackley & Ladwig, [Year]).

Short term goals:

1.Goal met.Client identified daytime napping, boredom
and coffee as possible sources of sleep problems.She identified elimination of the nap, reduction in coffee and sitting outside
on the balcony as strategies to address those sources at 11:45 AM on [Month] 14, [Year].

3.Goal partially
met.Client identified sitting on the
porch to watch people and watching TV as alternate activities.She was unable to provide a third.
Client problem-solving should continue to be encouraged and goal should be reassessed
on [Month] 21, [Year] by 15:00.

Long term goals:

1.Goal not
met.The client has made no progress
towards this goal. Evaluation is set for 15:00 on August 1, [Year].

2.Goal not
met.The client has made no progress
towards this goal. Evaluation of ability to regularly fall asleep without difficulty
is scheduled for 15:00, August 1, [Year].

3.Goal not
met.The client has made no progress
towards this goal. Evaluation of reduction in frequency of night awakenings is scheduled
for 15:00, August 1, [Year].

4.Goal not
met:The client has made no progress
towards this goal. Client is scheduled to verbalize effects of substance use on
sleep by15:00, [Month] 21, [Year]

Client provided sleep-wake history, medication
list, and a report of current levels of substance use at 12:10 PM on [Month] 14, [Year].

Initiated nonpharmacologic interventions
for improved sleep including providing diversional activity to increase stimulation,
increasing sunlight exposure by encouraging we speak outside on the balcony for
a period of 15 minutes, and teaching regarding the impact of cigarettes and alcohol
close to bedtime and the need to eliminate napping to alleviate boredom.Continued education is required to disseminate additional information on
promotion of sleep hygiene as well as reinforcement of past teaching.Reevaluation recommended by 15:00, [Month] 21, [Year].

Pursuant to current evaluation, continued
evaluation is recommended of current care plan weekly though 15:00, August 1, [Year].

Assessment

Subjective:

Client report
of difficulty falling and staying asleep.

Client verbalizations of “I sleep during
the day because I don’t have nothing to do,”
reported use of a three servings of alcohol daily, reported use of a pack of cigarettes daily
andverbalization of “I like to sit
here and watch TV” while describing her bedroom
activities.

Objective:

Client has a prescription for Ativan.

Client was disrupted for weekly meeting
from daytime naps on 4 of 8 visits.

Subjective Data:

Regarding inadequate stimulation, patient
stated, ““I sleep during the day because I don’t nothing to do.Regarding poor sleep hygiene, patient stated, “I like to sit here and watch
TV” while describing her bedroom activities. Regarding
substance use, client stated she consumes approximately a three servings of alcohol and smokes
a pack of cigarettes daily.